Form R-4 - Information To Be Furnished By Promoters, Directors, Officers And Partners Of, Issuers Or Investment Advisers - 2013 Page 3

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Form R-4
11/12
Page 3
7. State in full your arrangements with this organization regarding compensation, salary,
commission, profit-sharing, bonus, and any other payments made for any purpose within the
last three (3) years whether directly to you or to any person in whom you have a financial
interest. (Attach a separate sheet if necessary, marked Exhibit 2 ).______________________
___________________________________________________________________________
8. (a) What amount of your time do you devote to this organization’s business or affairs?
________________________________________________________________________
(b) Will you be engaged in such activities on a full-time or a part-time basis?_____________
9. Have you ever:
Yes
No
  
(a) Been an officer, director or promoter in a company which has
  
become insolvent?
  
(b) Been convicted of any fraudulent acts in any transaction of any
  
kind or character?
  

(c)
Been convicted of any misdemeanor involving a security or any
 
aspect of the securities business, or of any felony?
(d)
Been declared bankrupt, or made an assignment for the benefit
  
of creditors?

(e)
Been permanently or temporarily enjoined from engaging in or
  
continuing any conduct or practice involving any aspect of the

securities business?
Instruction: If the answer to any part of question 9 is in the affirmative, attach a separate
sheet providing full particular. If during the period of your association with
the issuer or investment adviser an event occurs which would cause a current
affirmative answer to any part of item 9, notify the Securities Regulation
Division in writing as to the facts relating to such event.

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